The crash of an Air France Concorde shortly after takeoff from Paris Charles de Gaulle Airport a decade ago was the result of a series of small mistakes, faulty assumptions and missed opportunities. They began with the design of the airplane. They continued until shortly before the takeoff roll. And they spanned events in the intervening years. It was a classic string of seemingly minor matters and improbable events adding up to tragedy.
But let us emphasize that word mistakes. At no point in this string of events did anyone knowingly do something wrong or shirk his or her responsibilities. Nonetheless, a court in Pontoise, France, last week determined that just one mistake was chiefly to blame for the crash and it was the act of criminals: Continental Airlines and mechanic John Taylor (see p. 37). This is wrong-headed and dangerous. But the problem is not the judge; the problem is the law.
First, this was no mystery to be solved. (“J’accuse! It was the mechanic, in the hangar, with the titanium strip.”) Years ago, the French accident investigation agency BEA resolved what happened. The BEA did a superb job of determining the causes of the accident, not only explaining the chain of events on July 25, 2000, but conducting its own tests and then putting everything into the context of systems design, previous incidents involving the Concorde and the remedial steps that had been taken as a result.
We may not agree with every subtlety of emphasis, but the BEA’s 2002 report was thorough and balanced. It found that a “lack of rigorous maintenance” at Continental had led to a wear strip on a DC-10 thrust reverser door being replaced with an improvised part that fell off on departure from CDG. Minutes later, the Concorde rolled over the strip, a tire exploded and there began a chain of events that destroyed the elegant bird.
Tire blowouts are not exotic events in aviation. Nor is FOD—foreign object debris—unusual. On the contrary, FOD is an everyday concern at airports large and small around the world.
For a modern commercial aircraft to be deemed airworthy, it must be able to survive a blowout. Before the accident, there had been 57 cases of Concordes’ tires bursting or deflating. Twelve of those incidents led to structural damage to a wing or fuel tank, and six of those led to penetrations of tanks. The bottom line is that, for the Concorde, there was a 10% chance a blowout could lead to a ruptured fuel tank.
Significantly, there are no uniform standards for what is acceptable FOD or how to find the junk that could cause harm, just general agreement to try to eliminate all debris. This is accomplished chiefly through periodic inspections. Because of the Concorde’s known vulnerabilities, there was an informal arrangement with airports to conduct additional visual checks for FOD before each takeoff. However, the BEA found “airworthiness oversight [for the Concorde] which could be considered as less reactive than for other types of aircraft.”
We bring this up not to shift blame from Continental to Air France, Aeroports de Paris or EADS (the successor to the Concorde’s developers) but to point out the futility of trying to assign blame at all. From purely a safety perspective, little good can come from going down this path. One might suppose that the threat of criminal prosecution would heighten the attentiveness of everyone in aviation. But safety is already of paramount importance.
More to the point, the specter of fines and jail time will have a chilling effect on the voluntary reporting of errors and retaining and sharing safety-related information. Today, a no-fault approach is producing some of the most significant improvements in safety. All the low-hanging fruit has already been picked. So broad analysis of even minor gaffes and routine operations is a vital tool to further reduce the already very low rate of aviation accidents.
Unfortunately, the trend toward “criminalizing” aviation accidents appears to be increasing internationally. Prosecutors in Brazil, Indonesia, Italy, Greece and Switzerland have also brought criminal charges after crashes where there was no intent to cause harm on the part of the individuals involved.
We do not argue for criminal immunity for pilots, mechanics, controllers, designers and manufacturers. But the need for justice must be carefully balanced with the broader need to be safe. Prosecutors and legislators should take that into consideration in crafting laws and applying them to aviation accidents.
If there is anything criminal about crashes, it is the damage that will be done to aviation safety in treating accidents as crimes.
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